Or. Admin. R. 309-018-0145 - Service Plan and Service Notes

(1) The Service Plan shall be a written, individualized plan to improve the individual's condition to the point where the individual's continued participation in the program is no longer necessary. The Service Plan is included in the individual's service records and shall:

(a) Be completed prior to the start of services;

(b) Reflect the full assessment and the level of care to be provided;

(c) Include a safety plan when the assessment indicates risk to the health and safety of the individual or to others and be updated as circumstances change. The safety plan may be a separate document from the Service Plan;

(d) Include the participation of the individual;

(e) Include the participation of family members as applicable; and

(f) Be completed and signed by qualified program staff as follows:

(A) Supervisory or treatment staff in substance use disorders treatment and recovery programs, and

(B) Supervisory or treatment staff in problem gambling treatment and recovery programs.

(2) At minimum, each service plan shall include:

(a) Treatment objectives that are:

(A) Individualized to meet the assessed needs of the individual; and

(B) Measurable for the purpose of evaluating, including a baseline evaluation.

(b) The specific services and supports used to meet the treatment objectives;

(c) A projected schedule for service delivery, including the expected frequency and duration of each type of planned therapeutic session or encounter;

(d) The type of personnel furnishing the services; and

(e) A projected schedule for re-evaluating the service plan.

(3) Providers shall document each service and support in a service note to include:

(a) The specific services rendered;

(b) The specific service plan objectives being addressed by the services provided;

(c) The date, time of service, and the actual amount of time the services were rendered;

(d) The personnel rendering the services, including the name, credentials and signature;

(e) The setting in which the services were rendered; and

(f) Periodic updates describing the individual's progress.

(4) The transfer of individuals shall be documented in the service notes and in accordance with OAR 309-018-0155.

Notes

Or. Admin. R. 309-018-0145

MHS 10-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14; MHS 3-2014, f. & cert. ef. 2-3-14; MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18; MHS 4-2018, amend filed 02/27/2018, effective 3/1/2018

Statutory/Other Authority: ORS 413.042, 428.205 - 428.270, 430.640 & 443.450

Statutes/Other Implemented: ORS 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991, 461.549 & 743A.168